The chief physiologic change that occurs with aging is decreased functional reserve: baseline function decreases a little but maximal possible function organ system decreases greatly. This results in decreased ability of the body to function optimally when under stress, such as that which accompanies a surgical procedure. The elderly are able to tolerate even large operations, but the very largest operations will challenge this functional reserve. Patients of the Center will undergo a more comprehensive screening and assessment of their individual status prior to surgical treatment. This evaluation will be highly beneficial in assisting the patient to work with his or her healthcare provider in determining their course of treatment.
In addition, there is growing recognition that cardiopulmonary evaluation in the elderly surgical patient may not be sufficient and that other “softer” tests may hold incremental value in discriminating surgical risk. These might evaluate frailty, cognition, activities of daily living, nutrition, delirium risk, falls risk, medications, and more. The results of this “leave no stone unturned” comprehensive evaluation will also be studied to determine what factors are most important in evaluating the risk of surgery as it pertains to each individual patient.
The components of the Center for Geriatric Surgery Clinical Program consist of:
Comprehensive Preoperative Evaluation
The Center’s Clinical Coordinator, a full-time Nurse Practitioner (CRNP), performs comprehensive preoperative evaluations of elderly surgical patients in the Sinai Hospital PreAnesthesia Screening Service (PASS) clinic. Evaluations will be based on the American College of Surgeons National Surgical Quality Improvement Project/American Geriatrics Society (ACS NSQIP/AGS) Best Practice Guidelines: Optimal Preoperative Assessment of the Geriatric Surgical Patient, and supplemented by the Zarit Burden Interview and others. These evaluations include routine physical examination and laboratory studies plus frailty, mini-cognition, activities of daily living, etc. Findings are entered into a database. Additional testing may be ordered as indicated. All medications are reviewed. Preoperative orders for antibiotics, deep vein thrombosis prophylaxis, and others are confirmed.
This is a guiding principle of the Center: not too little, not too much, not too limited and not too aggressive. Many studies have shown that the elderly tolerate complex operations and aggressive chemotherapy but are discriminated against solely on the basis of chronologic age. In some cases, however, lesser treatments provide nearly identical results with less stress of functional reserve. Finally, patients’ and families’ wishes must be honored.
The Clinical Coordinator is each elderly patient’s advocate during his or her in-patient postoperative stay, helping with daily medication review, family communication, and discharge planning.
The Nurses Improving Care for Health System Elders (NICHE) certifies hospitals which achieve systematic nursing change that will benefit hospitalized older patients. NICHE is the only national designation indicating a hospital's commitment to elder care excellence. Although not isolated to surgical patients, this hospital-wide approach to nursing quality---similar to Sinai’s Magnet Certification for overall nursing excellence---will benefit all and result in improved outcomes and greater patient and family satisfaction.